HomeMy Public PortalAbout5028 ARDEN DR_Mechanical__ � �WiirT th'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I,bereh�,�IIOQffirr� thGt I have a certificate of consent to self
4 - insu4r.. a certificate.of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
or a certif :d co0y thereof (Sec. 3800, Lab. C.) CC
� E 818(REV. 10/81)
Policy No. � 42- Company 57 � FUO
Certified copy is hereby furnished. .
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING ��`�
tion department. (PRINT OR TYPE ONLY) ADDRESS 2.84eaav
Date ` 8� _Applicant 8-` �T'f�o�`� LOCALITY �g
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST / /� /�
COMPENSATION INSURANCE CROSS ST. "JA)
/`FZGL ZIP /�
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. ESSED BY
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner PROC
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPEC O S SIGNAVJRE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'.
Compensation provisions of the Labor Code, you,must forth- EVAPORATIVE COOLER VALI ATION .
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. A.
rA G 4 Z Irl e5 7-cl ;21 9 612 A O
License Number Lic. Class — I ► V
# o o o a o
Contractor
�— Z.-3 �o.*/S7. Date = 0
I am exempt under Sec.
Ia 3050
Plan check fee a.
B.&P.C. for this reason' H
Date: PERMIT ISSUING FEE $ lU iSQ o 0 - 3Q503)
Signature TOTAL FEE Z25 O 5 0 1 -85
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY 7EL. NO.
7044, Business and Professions Code).
OWNER (/lf
❑. I, as owner of the property, am exclusively contracting MAIL t7�
with licensed contractors to construct the project (Sec- ADDRESS S�ZB A�o�� '✓/�-
tion 7044, Business and Professions Code). aJ
CONSTRUCTION LENDING AGENCY CITY T�1,�G� C� TEL. NO. '4"4 3
I hereby affirm that there.is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR/. Z _
(Sec. 3097, Civ. C.).
ADDRESS ��7 r /L � �s/✓��'
Lender's Name
CITY ��4���f TEL. NO. p��r
Lender's Address
STATELIC.
..,
I certify that I have read this application and state that the LICENSE NO. 32 %P 3Y Z CLASS X�
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
the above-m tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date